CERTIFICATE OF LIABILITY INSURANCE (418)lien t #:
ACORDTM CERTIFICATE OF LIABILITY
INSURANCE
Y)
10/29/2013
TYPE OF INSURANCE
PRODUCER
Ashbrook - Clevidence, Inc.
3000 W. MacArthur Blvd., #320
License #0188788
Santa Ana, CA 92704
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
Data Ticket, Inc. dba: Revenue Experts
4600 Campus Drive #200
Newport Beach, CA 92660
INSURER A: Hartford Casualty Insurance Co.
INSURER B: State Compensation Ins Fund
LIABILITY
COMMERCIAL. GENERAL LIABILITY
INSURER C. Continental Casualty Ins Co
INSURER D.
11/01/14
INSURER E.
$2,000,000
$300,000
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
ADD'L
INSRD
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM /DD/YY)
POLICY EXPIRATION
DATE (MM /DD/YY)
LIMITS
A
GENERAL
LIABILITY
COMMERCIAL. GENERAL LIABILITY
84SBAIA9147
11/01/13
11/01/14
EACH OCCURRENCE
$2,000,000
$300,000
X
DAMAGE TO RENTED
DAMAG ES R NT Erence!
CLAIMS MADE X OCCUR
MED EXP (Any one person)
$10 000
PERSONAL & ADV INJURY
$2,000,000
GENERAL AGGREGATE
$4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$4,000,000
POLICY n PRO-
JECT LOC
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
84SBAIA9147
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11/01/14
••�
(Eaaccident�INGLELIMIT
$2'000'000
BODILY INJURY
(Per person)
$
_
X
BODILY INJURY
(Per accident)
$
X
-
PROPERTY DAMAGE
(Per accident)
$
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
AUTO ONLY: AGG
$
A
EXCESS /UMBRELLA LIABILITY
84SBAIA9147
11/01/13
11/01/14
EACH OCCURRENCE
$1,000,000
71 OCCUR CLAIMS MADE
AGGREGATE
$1,000,000
DEDUCTIBLE
RETENTION $ 10000
$
X
$
B
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER /EXECUTIVE
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
90657312013
07/12/13
07/12/14
X I TORY W MIT S 1 IM-
E.L. EACH ACCIDENT
$1,000,000
$1,000,000
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$1,000,000
C
OTHER Professional
Liability (E & 0)
287188360
11/01/13
11/01/14
$2,000,000 Limit
$10,000 Retention
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Certificate Holder is named as additional insured as respects the general liability coverages as per the
attached verbiage from the policy.
CERTIFICATE HOLDER
CANCELLATION *10 Days for Non - Payment
City of Clearwater
P.O.Box 4748
City of Clearwater, FL
33758 -4748
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *iii DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) 1 of 2 #S25833/M25820
SXL
0 ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 -S (2001/08) 2 of 2 #S25833/M25820
BUSINESS LIABILITY COVERAGE FORM
F. OPTIONAL ADDITIONAL INSURED
COVERAGES
If listed or shown as applicable in the Declarations,
one or more of the following Optional Additional
Insured Coverages-also apply. When any of these
Optional Additional Insured Coverages apply,
Paragraph 6. (Additional Insureds When Required
by Written Contract, Written Agreement or Permit)
of Section C., Who Is An Insured, does not apply
to the person or organization shown in the
Declarations. •These coverages are subject to-the
terms and . conditions applicable •to Business
Liability . Coverage . in this policy, except as
provided below.
Additional insured - Designated Person Or
Organization
WHO IS AN • INSURED under Section C. is
.amended to include as an additional insured
the person(s) or organization(s) shown in the
Declarations, but only with respect to. liability
for bodily injury", "property damage" • or
"personal and advertising injury" caused, in
whole or in part, by your acts or omissions or
the .acts or omissions of those acting on your
behalf:
a. In the performance, of your ongoing
operations; or .
b. In connection. With your premises owned
- - •by or rented to you. .
2. Additional Insured - Managers Or Lessors
Of Premises
a. WHO IS AN INSURED under Section C. is
.amended to include as an additional insured
the person(s) or organization(s) shown in the.
Declarations as. an_ Additional Insured -
Designated Person Or Organization; but only.
• with respect to liability arising out of the
ownership, maintenance or use of that part of
the premises leased to you and shown in the
Declarations.
b. With respect to the insurance afforded to
• these additional insureds, the following
additional exclusions apply:
This insurance does not apply to:
(1) Any "occurrence" which takes place
after you cease to be a tenant in that
premises; or
(2) Structural alterations, new
construction or demolition operations
performed by . or on behalf of such
person or organization.
3. Additional Insured - Grantor Of Franchise
WHO IS AN INSURED under Section C. is
amended to include as an additional insured
the person(s) or organization(s) shown in the
Declarations as an Additional Insured -
Grantor Of Franchise, but only with respect to
-'their liability as grantor of franchise to you.
4. Additional Insured .- -.Lessor. Of Leased
Equipment
a. WHO IS AN INSURED under Section C. Is
amended to include • as an additional
insured the person(s) or Organization(s)
shown in the Declarations as an Additional
Insured — Lessor of Leased Equipment, •
but only with respect to liability for "bodily
injury", "property damage" or "personal
and advertising injury" caused, in whole or
in part, by your maintenance, operation or
use of equipment leased to you by such
person(s) o'r organization(s).
b. With respect to the insurance afforded to
these additional • insureds, this* insurance
does not apply to any "occurrence" which
takes place after you cease to lease that
equipment
5. Additional Insured - Owners Or Other
Interests From Whom", Land Has Been
Leased
• a. WHO IS AN INSURED under Section C. is
amended to include as an additional
insured the person(s) or organization(s)
shown In the Declarations as an Additional
Insured — Owners Or Other Interests From
Whom Land Has Been Leased, but •only -
with respect to liability arising. out of the
. ownership, maintenance cruse of that part
. • of the land leased to you and shown in the
• • Declarations.
b. With respect to the insurance afforded to
these additional insureds, the following
• additional. exclusions apply:
This insurance does not apply to:
(1) Any "occurrence" that takes place
after you cease to lease that land; or
(2) .Structural alterations, new
• construction or demolition operations
performed by or••on behalf of such
person or organization.
6. Additional Insured - State Or Political
Subdivision — .Permits
a. WHO IS AN INSURED under Section C. is
amended to include as an additional
insured the state or political subdivision
shown in the Declarations as an Additicns:i
P e a3 of 2 d. Form SS